VACCINE RECIPIENT INFORMATION

Name: (Last, First) Date of Birth: Age:

Address: Postal Code: Health Services Number:

Phone Number: Sex shown on health card:

O M O F O X O Not on card

EMERGENCY CONTACT Name: Phone Number:

Vaccine Screening and Consent Form (All Vaccines)

Inactivated vaccines including Influenza Vaccine: Q1-8; COVID-19 vaccine: Q1 -10; Live vaccines: Q1-8 and 11-13Vaccine Providers: see the accompanying guide for interpretation of responses Last updated 6 Mar 2022

The following questions will help determine if a vaccine is right for you. A “yes” to any question does not necessarily mean you should not be vaccinated, but your pharmacist may have some additional questions.

1. Do you feel sick today? O Yes O No

2. Do you have severe allergies to medications, food, a vaccine component or latex? If yes, please describe: O Yes O No

3. Have you ever had a serious reaction after receiving a vaccination? If yes, please describe: O Yes O No

4. Do you have any of the following medical conditions:

O Bleeding problems O Asthma O Lymphatic circulation impairment (e.g. lymphedema, axillary lymph node removal [mastectomy, lumpectomy], amputation)

O Autoimmune disorder? (e.g.: Crohn’s disease, lupus, multiple sclerosis, psoriasis, rheumatoid arthritis, type 1 diabetes)

O Cancer, HIV infection, Transplant, other immune system disorders

O Yes O No

5. Do you take any of the following medications (currently, recently):

O Blood thinners (e.g. aspirin, warfarin, Eliquis®, Lixiana®, Pradaxa®, Xarelto®)

O Medications that affect the immune system such as prednisone, other steroids, anticancer medications, transplant medications, medication used to treat inflammatory conditions (e.g. rheumatoid arthritis, Crohn’s disease, psoriasis). If unsure, ask your pharmacist

O Antiviral medications or antibiotics (medications used to treat infection)

O Yes O No

6. Are you pregnant, could you be pregnant or are you planning on becoming pregnant? O Yes O No

7. Are you nursing/breastfeeding? O Yes O No

8. Have you received any vaccinations in the past 4 weeks or have any scheduled vaccines in the upcoming 4 weeks? O Yes O No

Also answer Questions 9 to 10 if you will be receiving a COVID-19 vaccine

9. Have you had a previous COVID-19 infection? O Yes O No

a. If yes to Q9, were you treated with convalescent plasma or monoclonal antibodies? O Don’t know O Yes O No

10. Do you have a history of: O Myocarditis or Pericarditis O Multisystem Inflammatory Syndrome in Children (MIS-C) O Yes O No

Also answer Questions 11 to 13 if you will be receiving a live vaccine

11. Do you require a TB skin test within the next 4 weeks or have you ever had a positive TB skin test? O Yes O No

12. Do you have close contact with anyone with a weakened immune system? O Yes O No

13. In the past year, have you received a transfusion of blood/ blood products, or immune globulin (Ig)? O Yes O No

SCREENING

PLEASE SIGN ON REVERSE

DECLARATION OF CONSENT: • I have read or had explained to me the vaccine information sheet regarding the risks, benefits and potential side effects associated with the vaccine(s) and risks of not vaccinating. • I have had the opportunity to have my questions answered by the pharmacist and understand the information I have been given. • I understand the need for observation by the vaccine provider for at least 15 minutes after my vaccination and that in the rare occurrence of anaphylaxis, emergency treatment will be provided. • I understand health information may be shared with another healthcare provider as necessary for care. • I am the lawful parent/guardian entitled to make health care decisions for my child/dependent. • I consent to the vaccine provider administering the vaccine for myself or my child/dependent. • If applicable, I designate to accompany my child for a vaccine(s).

Signature of: Name (if not signed by vaccine recipient) DateO Vaccine Recipient O Parent /Guardian O Proxy

Assessing Pharmacist:

For Pharmacy Use Only

O Discussed publicly funded options (if applicable)

Vaccine: Name, Manufacturer, DIN*, LOT#, Expiry Date Dosage Site Route Dose # Administered by

(Name)Date & Time of Injection

1.

O Age appropriate O Minimum interval met (if applicable)

2.

O Age appropriate O Minimum interval met (if applicable)

3.

O Age appropriate O Minimum interval met (if applicable)

4.

O Age appropriate O Minimum interval met (if applicable)

Adverse reaction: O No OYes – Vaccine(s) implicated: Describe reaction:

O Completed Adverse Event Following Immunization (AEFI) form

O Provided record of immunization

O Notified primary care practitioner (NOT for COVID-19 or Influenza) Name: Fax:

*Not required as per bylaws but good practice to record No part of this work may be reproduced, distributed, or transmitted in any form or by any means unless authorized by medSask. For copyright permission requests, please contact druginfo@usask.ca. Last updated 6 Mar 2022

Name of Adult

Financial contribution from